Pharmacy Benefit Managers

Mattingly, T. Joseph; Hyman, David A.; Bai, Ge

doi:10.1001/jamahealthforum.2023.3804

Cited by 6 publications

(1 citation statement)

References 37 publications

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“…Although the specific individuals involved in creating these protocols can vary, they often include a combination of pharmacists and physicians, with consultation of clinical guidelines and expert opinions. 25,26 The consistency between treatment guidelines and step therapy protocols regarding first-line treatments varies depending on the disease. In an analysis of protocols from 17 of the largest U.S. commercial health plans, step therapy protocols are least consistent with treatment guidelines for the diseases with the largest number of pharmaceutical treatments: psoriasis, rheumatoid arthritis, psoriatic arthritis, and multiple sclerosis.…”

Section: Impact Of Safe-step Act On Physiciansmentioning

confidence: 99%

Analyzing the Benefits and Costs of the Safe Step Act on Patients, Physicians, and Insurers

Shan,

Greenzaid,

Greene

et al. 2024

Journal of Psoriasis and Psoriatic Arthritis

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Pharmaceutical expenditures in the United States, particularly in dermatology, have grown rapidly, driven by expensive topical and biologic treatments. Insurers are employing cost-containing strategies such as step therapy, which mandates the use of lower-cost treatments before more expensive medications. The bipartisan Safe Step Act aims to enhance step therapy policies by introducing a transparent process for requesting exceptions and reasonable timelines for the process. However, there is limited analysis on how the Safe Step Act would affect the healthcare environment. We examine the policies of the Safe Step Act and existing literature on prior authorizations and discuss how the bill could affect patients, physicians, and insurers. While the act could expedite access to necessary medications and prevent irreversible harm to patients from delaying efficacious treatment, it falls short in relieving the administrative burdens on dermatology clinics. Although there is no ideal solution for managing healthcare costs, measures like step therapy encourage cost-effective treatments and optimizing care for the population. Curtailing step therapy with the exemptions process of the Safe Step Act might streamline patient access to treatments but could impede cost-containment strategies, weaken the bargaining power of insurers, and result in higher insurance premiums.

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Section: Impact Of Safe-step Act On Physiciansmentioning

confidence: 99%

Analyzing the Benefits and Costs of the Safe Step Act on Patients, Physicians, and Insurers

Shan,

Greenzaid,

Greene

et al. 2024

Journal of Psoriasis and Psoriatic Arthritis

View full text Add to dashboard Cite

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Strategies to Help Patients Navigate High Prescription Drug Costs

Lalani,

Hwang,

Kesselheim

et al. 2024

JAMA

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ImportanceIn the US, many patients struggle to afford prescription drugs, leading to adverse health outcomes. To improve cost-related medication nonadherence, prescribers and clinical staff must understand how to assist patients in overcoming high prescription drug costs.ObservationsWe reviewed the benefits and limitations of 7 strategies to help patients afford prescription drugs: co-payment cards, patient assistance programs, pharmacy coupons, direct-to-consumer pharmacies, public assistance programs, international online pharmacies, and real-time prescription benefit tools. We created an algorithm to help clinicians identify appropriate strategies based on a patient’s health insurance and the type of drug (brand-name vs generic). For example, co-payment cards can lower out-of-pocket costs for privately insured patients taking brand-name prescription drugs. For uninsured individuals or those with public insurance like Medicare Part D who meet financial eligibility criteria, patient assistance or public assistance programs may be available. All patients, regardless of health insurance, can forgo insurance and purchase drugs directly using pharmacy coupons or direct-to-consumer pharmacies, which sometimes offer lower prices for generic drugs compared to insurance. For insured patients, such purchases do not count toward insurance deductibles or annual out-of-pocket maximums. Online international pharmacies provide a last resort for patients in need of brand-name drugs who lack affordable domestic options. Increasingly, prescribers can use real-time prescription drug benefit tools to estimate patient out-of-pocket costs and identify alternative lower-cost treatments for insured patients, but these tools can be inaccurate or incomplete.Conclusions and RelevanceThe current patchwork of strategies to help patients manage high prescription drug costs highlights the structural and policy challenges within the US prescription drug market that impede affordable access for some patients. While these strategies provide tangible solutions for clinicians to help patients access medically appropriate but costly medications, they do not address the root causes of high drug prices.

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